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Carrying out fraud investigation in a health care environment.

Health care has entered into a new era of attention and political significance. However, not all of the attention is positive. With the money being pumped into the industry, there is also a raise in those hoping to exploit the raising growth, and to make illicit profit off the sometimes lacking security infrastructure. Carrying out effective fraud investigation in the health care environment will be a prominent feature told curtailing such malpractices and bringing about a stronger health care system in general. Health care fraud is a category of white-collar crime that involves the filing of dishonest health care claims for the purpose to turn a profit or other nefarious purposes. Fraudulent health care schemes come in many forms. Illegal schemes include billing for a non-covered service as a covered service, modifying medical records, prescribing additional or unnecessary treatments, and an assortment of other practices. It is an activity that has a significant economic impact on the whole system. To compensate for the losses that occur when an act of health care fraud is perpetrated, the health care provider passes the costs along to its customers. This has proven to be costly indeed; because of the vast scope of health care fraud, statistics now indicate that ten cents of every dollar spent on health care in the United States goes toward paying for fraudulent health care claims. Within the European Union, over €56 billion is lost to healthcare fraud each year. Financial concerns are not the only dire effects that result from health care fraud. Patient safety is also a prime concern. The health and safety of patients is endangered by the fraudulent practice of incorrect coding. Rather than only providing codes for confirmed diagnoses, physicians may throw in other codes, called kitchen sink coding, for increased profits on billing. This paperwork can then be used down the road as justification for the treatment of preexisting conditions they may never have existed. Patients can be subjected to uncomfortable and potentially dangerous procedures. Patients can be charged for a costlier diagnosis than actually carried out called the up-coding. An example of the devious activities such investigations try to curtail can be seen in the case of Sonya Lewis Williams. According to court documents, Williams operated two companies known as Fusion Services, LLC and Grace Social Services, LLC. Williams established the two companies for the purpose of using unlicensed social workers to visit Medicare beneficiaries at their residence several times a week; supposedly these social workers were to perform case management, counselling, and social communication services. Williams was found to have submitted false claims for reimbursement from Medicare, indicating that the beneficiaries had received personal, face-to-face psychotherapy from a licensed clinical social worker. However, no such services had ever been provided. Medicare paid Fusion and Grace an estimated $349,715 as a result of these fabricated billings. Much of the profits were then transferred from company bank accounts into Williams’ personal accounts. . On September 5, 2013, in Baton Rouge, Louisiana, Williams was sentenced to 37 months in prison for health care fraud and money laundering. Fraud investigators in the field of health care tend to be employed by insurance companies, and are referred to as insurance investigators. These investigators review and analyse medical claims filed by patients, providers and other insurance carriers which appear dubious. They run official inquiries by looking at medical records, interviewing relevant health care personnel and associated parties, as well as communicating with insurance claims adjusters. Medical fraud investigators, when necessary, will also gather and document evidence and direct such findings to state or national regulatory authorities. Fraud investigators require an expansive skill set to succeed within the vast scope of health care industry inquiries. These individuals need to understand how to follow a data trail, use case tools, review digital evidence and conduct forensic analysis. A strong background in leveraging technology is crucial, particularly because of the transition to electronic record keeping prevalent within the health care industry. It is also becoming more important to possess knowledge of different financial and legal systems, due to the increasing scope of internationally orchestrated fraud activities; this is especially true within developing nations. The world is constantly evolving; with new technologies and industry infrastructures comes new and creative ways for criminal activity to be conducted. This is no truer than in the sphere of health care. Through the work of fraud investigators within the industry, health care providers can fight back against those who hope to corrupt this vital social system.

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